You are closing out the week of clients and you still have 5 charting notes to finish. Sound familiar? Charting can be stressful for new practitioners. It might take you longer in the beginning because it serves as an opportunity to learn and grow as a new practitioner. Which charting note format should you use for your practice? Let’s explore SOAP vs ADIME.
Whether it is SOAP or ADIME. There is no right or wrong format. You need to use the format that is right for you! If you learned a system in school then stick with that for a while or modify it to work for your practice.
If your notes are taking you 10 hours then something needs to change. This is not sustainable or a successful clinical practice.
1) Craft time in your schedule to do your charting notes.
2) Chart during your appointment
3) Write less
4) Do less at each appointment, chunk it out
5) Get a simpler charting note
6) Use the dictation app on your computer
7) Get electronic health record (EHR) or electronic medical record (EMR) like Get Healthie or Practice Better.
Let’s explore some pros and cons for the two types of charting notes that a nutritionist uses in practice.
ADIME -Assessment, Diagnosis, Intervention, Monitoring, and Evaluation
PROS
● Very guided, fill in the blank
● Thorough assessment
● Standard documentation for licensed nutritionists/dieticians
● Useful in group practice/institutionalized setting
CONS
● Not a good form in “red” states where scope of nutritionist is limited
● No space for narrative
● Harder to fill out during consult
SOAP- Subjective, Objective, Assessment, Plan
PROS
· Fluid for writing content/narrative
· Can be super simple or more tailored
· Universal charting method across professions/practices
· More useful when scope of practice is limited
CONS
· Does not offer all the reminders/boxes that an ADIME note would offer
Less data oriented